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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 23  |  Issue : 3  |  Page : 162-167

Short-term evaluation of clear corneal incision after phacoemulsification using anterior segment optical coherence tomography


1 Department of Ophthalmology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
2 Department of Ophthalmology, Assiut Faculty of Medicine, Assist University, Assiut, Egypt

Date of Submission13-Jan-2022
Date of Decision16-Feb-2022
Date of Acceptance14-Mar-2022
Date of Web Publication30-Jul-2022

Correspondence Address:
Ahmed Ali A Amer
Department of Ophthalmology, Qena Faculty of Medicine, South Valley University, Qena 83523
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/djo_3_22

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  Abstract 


Purpose The aim of this study was to investigate the ultrastructure of corneal incisions after phacoemulsification by anterior segment optical coherence tomography (AS-OCT).
Patients and methods This is a prospective interventional study of 50 eyes of 50 patients with senile cataract attending the Outpatient Clinic of the Ophthalmology Department, Qena University Hospital, Qena, Egypt, for whom clear corneal-incision phacoemulsification was performed from July 2020 to July 2021. The patients had preoperative and postoperative AS-OCT, and were followed up at 1 week, 2 weeks, 1 month, and 3 months, postoperatively. The four AS-OCT features that were studied were corneal thickness at the site of the main incision, epithelial and endothelial changes at the wound, and Descemet’s membrane detachment.
Results The mean age of the patients was 62.16±7.71 years. The mean corneal thickness was 768.06±102.03, 883.24±96.59, 841.98±100.70, 797.68±98.12, and 782.26±101.66 μm preoperatively, at 1 week, 2 weeks, 1 month, and 3 months postoperatively, respectively (P<0.001). Descemet’s membrane detachment was observed in nine (18%) and seven (14%) patients at 1 and 2 weeks postoperatively, respectively. Epithelial gaping was observed in five (10%) patients at 1 week and in two (4%) patients at 2 weeks. It was not observed after 1 month, postoperatively. Endothelial gaping was observed in 36 (72%) patients at 1 week, in 30 (60%) patients at 2 weeks, and in four (8%) patients at 1 month, and was not present after 3 months.
Conclusion AS-OCT is an excellent tool to assess the integrity and structure of the corneal wound after phacoemulsification sensitively and quantitatively. So, it could play an important role in the early detection and management of endophthalmitis.

Keywords: anterior segment optical coherence tomography, Descemet’s membrane detachment, endothelial gaping, epithelial gaping


How to cite this article:
Abdelmaged HA, Aldghaimy AH, Ali TA, Amer AA. Short-term evaluation of clear corneal incision after phacoemulsification using anterior segment optical coherence tomography. Delta J Ophthalmol 2022;23:162-7

How to cite this URL:
Abdelmaged HA, Aldghaimy AH, Ali TA, Amer AA. Short-term evaluation of clear corneal incision after phacoemulsification using anterior segment optical coherence tomography. Delta J Ophthalmol [serial online] 2022 [cited 2022 Dec 3];23:162-7. Available from: http://www.djo.eg.net/text.asp?2022/23/3/162/353033




  Introduction Top


Modern techniques in cataract surgery aim to achieve better unaided visual acuity and earlier postoperative recovery [1]. The clear corneal-incision (CCI) technique is commonly used during phacoemulsification cataract surgery [2]. Its advantages include shorter procedure duration, rapid postoperative wound recovery, minimal induced astigmatism, and minimal bleeding [3]. However, it has been reported that CCIs are associated with an increased risk of postoperative infection due to postoperative wound dehiscence and leakage [4],[5].

CCI assessment, especially immediately after surgery, is of interest because its integrity may reduce the occurrence of endophthalmitis and other postoperative complications [6].

CCI assessment can be performed by slit-lamp microscopy with or without gonioscopy, confocal microscopy [7], and ultrasound biomicroscopy (UBM) slit-scan tomography [8]. However, slit-lamp microscopy does not enable the examiner to detect and quantify the early structural changes related to the incision, especially if there is significant corneal edema. Neither confocal microscopy nor UBM have sufficient resolution to capture the fine structure of corneal incisions. Furthermore, UBM requires contact and a cumbersome water bath of the eye, which makes it inconvenient for the patient [9]. Recently, anterior segment optical coherence tomography (AS-OCT) has enabled qualitative analysis of anatomical and structural changes in the cornea as it allows for visualization of the corneal ultrastructure in real time [9].

The aim of this study was to evaluate epithelial gaping, endothelial gaping, corneal thickness, and Descemet’s membrane detachment (DMD) by AS-OCT following phacoemulsification.


  Patients and methods Top


This is a prospective cohort, analytical and interventional study that was carried out on 50 eyes of 50 patients with decreased visual acuity due to senile cataract of variable density who attended the Outpatient Clinic of the Ophthalmology Department, Qena University Hospital, Qena, Egypt, from July 2020 to July 2021. The patients’ age ranged from 55 to 75 years.

The research protocol was designed in accordance with the Declaration of Helsinki and the Medical Research Council’s Guidelines for Ethical Biomedical Research on Human Subjects. The Institutional Ethics Committee of Qena Faculty of Medicine, South Valley University, Qena, Egypt, approved the research (SVU/MED/OPH026/1/2020/7/49). All patients signed a written informed consent to participate in the study and for publication of data before enrollment in the study.

Noncompliant patients and patients with glaucoma, corneal pathology, sutured corneal wounds, inflammatory eye diseases, history of ocular surgery or trauma, and intraoperative complications were excluded from the study.

All patients were subjected to preoperative examination, including best-corrected visual-acuity testing using Landolt’s broken-ring chart, which was then converted to LogMAR for statistical analysis, slit-lamp examination of the AS with determination of the type of cataract, Applanation tonometry, fundus examination after pupil dilatation, B-scan ultrasonography (if the media were opaque), and AS-OCT with a high-speed AS-OCT device (SPECTRALIS Anterior Segment Module, Heidelberg, Germany). Thereafter, clear corneal phacoemulsification with posterior chamber in the bag intraocular lens implantation was performed. The patients were followed up by AS-OCT at 1 week, 2 weeks, 1 month, and 3 months, postoperatively. During each visit, the patients were subjected to best-corrected visual-acuity testing, slit-lamp evaluation, and intraocular pressure measurement.

The wound anatomy was directly visualized using the SPECTRALIS AS-OCT.

The following four features were used to describe the architecture of the incision:
  1. The maximum corneal thickness at the site of the main incision.
  2. The changes at the epithelial side of the wound.
  3. DMD.
  4. The apposition at the endothelial side of the wound.


Statistical analysis

The collected data were tabulated and statistically analyzed using the Statistical Package for Social Sciences (SPSS) program (IBM_SPSS. Ver. 23, Standard version, 2012–2013, Copyright; SPSS Inc., Armonk, New York, USA). Normally distributed quantitative variables were presented as mean±SD and skewed quantitative variables were presented as median and interquartile range. Categorical variables were presented as frequencies and percentages. For continuous variables, independent-sample t test was carried out to compare the means between groups. Multivariate logistic-regression analysis was calculated to investigate the independent significant predictors of viability (odds ratio – 95% confidence interval). A P value less than 0.05 was considered statistically significant.


  Results Top


The mean age of the patients was 62.16±7.71 years (range=55–75 years), with 12 (24%) male patients and 38 (76%) female patients, with a male-to-female ratio of 1 : 3.

The mean corneal thickness after phacoemulsification was 883.24±96.59, 841.98±100.70, 797.68±98.12, and 782.26±101.66 μm at 1 week, 2 weeks, 1 month, and 3 months postoperatively, respectively, with a statistically significant difference in the corneal thickness between the postoperative follow-up periods (P<0.001, [Figure 1]a and [Table 1]).
Figure 1 (a) Measurement of the corneal thickness at the wound site. (b, c) Two cases of Descemet’s membrane detachment (DMD). (d) A case of endothelial gaping.

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Table 1 Corneal thickness during the follow-up

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Epithelial gaping was noticed in five (10%) patients at 1 week and in two (4%) patients at 2 weeks, postoperatively, and was reduced significantly to 0% after 1 month (P=0.019, [Table 2]).
Table 2 Postoperative epithelial gaping

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DMD was noticed in nine (18%) eyes and seven (14%) eyes at 1 and 2 weeks postoperatively, respectively. It was reduced to one (2%) eye at 1 month postoperatively and was not detected in any eye 3 months, postoperatively. There was a significant decrease in the rate of DMD during the follow-up time, until it dropped to 0% at the third postoperative month (P=0.002, [Figure 1] b and c and [Table 3]).
Table 3 Postoperative Descemet’s membrane detachment

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Endothelial gaping was observed in 36 (72%) cases at 1 week postoperatively, with a statistically significant decrease in its incidence over the follow-up period. It dropped to 0% after 3 months (P<0.001, [Figure 1]d and [Table 4]).
Table 4 Postoperative endothelial gaping

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  Discussion Top


CCIs are the most commonly used incisions by cataract surgeons around the world [10],[11]. However, the reliability of CCIs and whether they increase the risk of endophthalmitis are still subjects of debate [12].

The introduction of AS-OCT has given the researchers the opportunity to evaluate the incision sites in vivo. Using this noninvasive, noncontact technique, the patients can be examined within minutes after surgery without risk. AS-OCT systems display not only static parameters such as the incisional architecture (angle, length, thickness, and configuration) but also the dynamic healing processes [13],[14],[15].

Bolz et al. [16] found that the postoperative increase in corneal thickness was greater in the vicinity of the incision site, which demonstrates the impact of the phaco tip on the incision site. In addition, Lundberg et al. [17] found strong correlations between the loss of endothelial cells postoperatively and the corneal swelling resulting from the surgical trauma. Based on the results of the current study, there was a statistically significant difference in the corneal thickness between the preoperative, and the 1-week, 2-week, 1-month, and 3-month postoperative periods. Similarly, Peng and Liu [18] found that incisional corneal thicknesses were significantly different at variable postoperative time points, even 3 months postoperatively.

DMD usually cannot be detected under biomicroscopic evaluations even though it occurs in at least 50% of cases on the first postoperative day [3],[19],[20],[21]. The rate of DMD, in the current study, was lower, and such a difference could be attributed to the fact that AS-OCT in these studies was done 1 day after surgery, while in the current study, it was done 1 week after surgery. AS-OCT shows that the DMD rate after 1 week was 18%, and after 2 weeks, it was 14%. It was noticed that the DMD rate dropped to 2% after 1 month and to 0% after 3 months. Stromal hydration might be the cause for this decrease. Because corneal stromal lamellae and Descemet’s membrane have different physical features, the former could become swollen with water, while the latter could maintain its properties without swelling. Tangential forces between these structures may lead to DMD. Wang et al. [22] carried out a study to evaluate the long-term wound-healing changes in clear corneal cataract incisions using Fourier-domain OCT. Multiple OCT images were obtained for consecutive eyes that underwent phacoemulsification from day 1 to 18 months, postoperatively. DMD was present in 37.1% of the eyes at 1 day postoperatively, in 4.5% of the eyes at 1–3 months postoperatively (P<0.005), and in 0% of the eyes at 3 months postoperatively.

Xia et al. [23] carried out a study to investigate the ultrastructure of CCIs 24 h after phacoemulsification using AS-OCT. Images of the ultrastructure of the corneal incisions were taken via AS-OCT before and 1 day after surgery. The corneal thickness increased at the incision site after surgery in all eyes (P<0.001). DMD was observed in 49 (82%) of the eyes. This seemed to be associated with lower preoperative intraocular pressure (P=0.01).

In the present study, epithelial gaps were detected in five (10%) eyes after 1 week. There was a significant decrease in the rate of epithelial gaping during the follow-up, until it was reduced to 0% after 1 month. The current literature reports 100% epithelial closure on the first postoperative day [6],[8],[24]. The theory is that during the incision-closure process, the epithelial side of the wound seals first. With the pump function of the endothelial cells, suction occurs within the wound, which opposes the wound margins [25]. The gaping in the epithelium counteracts the suction and barrier mechanisms, which predisposes patients to endophthalmitis. Based on the results of the current study, it was believed that a noninvasive, noncontact technique such as AS-OCT should be used routinely, especially during the early postoperative period.

Wang et al. [22] reported endothelial wound gaping in 85.7% of the eyes at the first postoperative day and in 31.8% of the eyes at 1–3 months (P<0.001), and it was absent after 3 months. This finding is in line with the results of the current study as after 1 week, the rate of endothelial gaping was 72%. One month postoperatively, the rate of endothelial gaping was 8%, which is higher than that reported in a recent study by Yuksel et al. [26] (0% endothelial gaping at 1 month). However, there was a significant decrease in the rate of endothelial gaping during the follow-up period, with the value decreasing to 0% after 3 months. Xia et al. [23] reported gaping at the internal aspect of the corneal wound in 42 (70%) eyes. Eyes with gaping had thicker localized corneas (P=0.002).


  Conclusion Top


AS-OCT is an excellent tool to assess the integrity and structure of the corneal wounds after phacoemulsification sensitively and quantitatively. So, it could play an important role in the early detection and management of endophthalmitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Lundström M, Barry P, Henry Y, Rosen P, Stenevi U. Evidence-based guidelines for cataract surgery: guidelines based on data in the European Registry of Quality Outcomes for Cataract and Refractive Surgery database. J Cataract Refract Surg 2012; 38:1086–1093.  Back to cited text no. 1
    
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Shanmugam VK, Fernandez SJ, Evans KK, McNish S, Banerjee AN, Couch KS et al. Postoperative wound dehiscence: predictors and associations. Wound Repair Regen 2015; 23:184–190.  Back to cited text no. 4
    
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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